Featured Sequence: Gentle All-Around Practice

by Nina

This short sequence is designed for anyone who wants to get started with a short, gentle home yoga practice. This sequence is a great complement to our Low Back Care Practice and Mini Restorative Practice because it focuses on upper body flexibility, strength and balance, which are not addressed by the other sequences.

Although I originally designed this practice, Baxter reviewed it and made a modification—so it is officially Dr. Baxter Bell approved. We both hope you enjoy the practice!

1. Standing Shoulder openers (see Opening Tight Shoulders).

Releasing tight shoulders is important for the upper back and neck health, and is an important antidote for time spent in front of computers, driving, gardening, or other activities where you are reaching forward all day. If you have limited range of motion in one shoulder, just do the best you can, even if that means, for instance, taking your hand only half way up the wall rather than all the way. To make the sequence shorter, you could skip some of stretches (and alternate on different days of practice).

2. Half Dog pose at the Wall (see Half Dog Pose at the Wall). 

This pose is a wonderful all-over stretch because as it opens your shoulders it also stretches the sides of your torso, and, if you straighten your knees, it stretches the backs of your legs as well. It’s a perfect warm-up for standing poses!

3. Warrior 2 and Warrior 1 Mini Vinyasas (see Warrior 1 and Warrior 2 Mini Vinyasas).

Warrior 1 and Warrior 2 are classic standing poses that improve your balance (due to their wide leg stance), build leg strength (due to the bent front knee) and increase upper body strength (due to holding arms out to the side or over head). Practicing these as mini vinyasas (moving in and out of the poses with your breath), will improve balance and agility, and are a gentle versions of these poses. (Though this is not as strengthening as holding the poses for extended periods.)

For the Warrior 1 vinyasa, if you can’t hold your arms overhead, you can keep them in Namaste (prayer position) in front of your chest or place your hands on your hips.

4. Tree pose. 

Depending on your self confidence and your ability to balance, you can do this pose in any number of ways. If doing the pose in the middle of the room causes stress, stand in Tadasana (Mountain pose) with your left side near the wall. Shift your weight to the your left leg—if needed use your left fingertips on the wall to balance—and lift your right foot into any of the following positions:

• toes of the right foot on the floor, rest of the foot off the floor
• right foot on top of your left foot— but try not to have your right toes touch the floor
• sole of the right foot pressing against your left calf
• sole of your right foot pressing against your left thigh (above the knee)

5. Chair Twist (see Simple Chair Twist).

This pose releases back muscles that are stiff or sore from sitting at a desk or from traveling, or from everyday activities that stress the back, such as gardening and painting, and increases the rotational mobility in your spine. Twisting also helps nourish the spine—movement of the spine helps maintain the health of the discs—and also strengthens the bones themselves as your back muscles pull on the bony insertions of the spine. And it also strengthens the oblique muscles of your core. If you have a history of low back problems, please do this pose with a block between your thighs and twist only from the navel on up.

6. Easy Inverted Pose (see Easy Inverted Pose).

Resting your calves on a chair with a support under your pelvis puts your body into a slightly inverted position, so the blood flows from your legs down toward your heart making this pose a very calming inversion, which is also very restful for your leg muscles. If the support under your pelvis irritates your lower back, you can simply do the same pose without it.

NOTE: If you're reading this on the day it was posted, keep your eye out for a second post that recommends a weekly routine (including this sequence) that would be beneficial for anyone with back problems or who just wants to start practicing yoga at home.

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The Next Phase of Healthcare Information Exchange

Today, Massachusetts Governor Deval Patrick will launch the next phase of healthcare information exchange (HIE) in Massachusetts - “Commonwealth Interconnected:  Mass HIway Query and Retrieve”

In Phase 1 of our state HIE project, we focused on the Meaningful Use Stage 2 Direct protocol, enabling transition of care summaries, public health reporting transactions, and labs to flow over a state operated secure infrastructure.

In Phase 2, we solved a much harder and more complex problem - the pulling of records in real time from physician offices and hospitals where patients have opted in to disclose their records to other caregivers.

This required the engineering of several components
*A state wide master patient index for patients who opt in, storing name, gender, date of birth and other demographic data elements
*A state wide consent registry indicating the medical record numbers and locations where patients have opted in to disclose their data to caregivers
*A portal which enables providers to securely login and view patient medical record locations
*A viewer which enables secure retrieval of medical records from organizations which support real time data display
*An electronic medical record request system for those organizations which support a request/release by the medical records department workflow.
*Full audit trails of all activity - an accounting of disclosures

Today a multi-organizational team will demonstrate an Emergency Department visit by a febrile, confused, elderly gentleman.   His records are scattered over many hospitals and clinician offices.   Treatment in an emergency room is accelerated, more aligned with patient/family care preferences, and is safer with more information.   We'll demonstrate how a single institutional record based on one episodic visit can be very different than a lifetime continuous record which includes the entire patient experience with healthcare.     We'll show several near misses with diagnostics and therapy that could have caused harm, increased expense and reduced quality.

Today is the launch of the service.   The state's master patient index and consent registry (collectively called the relationship locator service) will be populated as patients consent to be included.   57 organizations including providers, public health, health plans, local HIEs and clinical registries are already part of the Massachusetts HiWay and all will be working hard in 2014 to expand the use of the new services.

I can imagine a day in the next few years, when all patients in the Commonwealth, with their consent, benefit from secure, coordinated care.    My mother suffered a major medical error in California because of inaccessible primary care records.   I truly believe that my 20 year old daughter, attending Tufts University, will see significant reduction in preventable harm in Massachusetts during her 20's.

Let the safety begin!

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Overcoming Addiction through Yoga and Meditation

by Ram

Red by Melina Meza

Addiction is a continued repetition of a behavior or practice or action despite adverse consequences that is beyond voluntary control. People with an addiction do not have control over what they are doing, taking or using and thus resort to an addictive behavior that interferes with daily responsibilities including family, work, relationships, or health. People with an addiction cannot control their addictive behavior; they become completely dependent or preoccupied with the substance or behavior, and may not be aware that their behavior is out of control thus causing problems for themselves and others. Examples of addictions include but are not limited to smoking, drug abuse, exercise addiction, food addiction, sexual addiction, computer addiction and gambling. The difference between addiction and habit is clear. Addiction is a psychological/physical component where the individual is unable to control the aspects of the addiction while a habit is done by choice and the individual is in a position to stop it successfully if he or she wants to. Habits do not have adverse consequences or a serious psychological/physical component as with an addiction.

Furthermore, with addictions, the body and the mind “wire in” the continuous repetitive task by incorporating it as a “normal” function. This creates the conditions of tolerance and withdrawal. When the addiction is to smoking or drug abuse, the body continually adapts to the substance and requires increasingly larger doses to achieve the distinctive effects. This is “tolerance” On the other hand, “withdrawal” refers to physical and psychological symptoms that arise when reducing or abstaining from the addictive behavior on which the body has become dependent. Withdrawal symptoms kick in due to biochemical and hormonal imbalances due to the lack of the addictive behavior. Thus, an addictive behavior may be associated with an immediate gratification but is also characterized by a delayed harmful effect (short-term reward versus long-term penalty).

The consequences of an addictive behavior on the body and brain include a large range of injuries, health problems, brain damage, and birth defects. Substance abuse and dependence trigger negative outcomes including injuries, illnesses, accidents, domestic violence, disabilities, medical problems and death. Treatment options include self-help groups, detoxification-inducing drugs to combat addiction, antibody therapy, vaccine therapy, and deep brain stimulation among others. However, true recovery is a very long journey. Some individuals will remain steadfast, some will relapse, and some will always be “chronic relapsers.”

But now there’s the good news that rehabilitation therapies that use yoga and meditation are likely to have a higher success rate when it comes to helping overcome addiction and relapse. The practice of yoga and meditation exert positive influence on addictive behaviors and helps addicts to understand their true nature. In addition, yoga and meditation helps addicts develop a detached awareness of thoughts since any attachment to them becomes the cause for suffering. Individuals with an addictive behavior and who have a regular practice of yoga and meditation have less blame and disrespect toward themselves and exhibit more respectful, caring, and loving behaviors.

Yoga and meditation also appear to be beneficial in specific type of eating disorders that constitute addiction as they change the addict’s perspective of their own disturbing personalities. In one such study, Exploring the therapeutic effects of yoga and its ability to increase quality of life, female yoga practitioners not only exhibited positive feelings and sense of well-being but they also reported less self objectification, greater satisfaction with their body images and reduced messy eating attitudes compared to non-yoga practitioners. Similarly in a recently published paper A computational hypothesis for allostasis: delineation of substance dependence, conventional therapies, and alternative treatments, a group of scientists used a computational model of addiction, a literature review and an in silico experiment to suggest that rehabilitation strategies that include yoga and meditation with drug and behavior therapies are more helpful than all other methods to help people overcome addiction. The authors argue that a combination therapy that include yoga and meditation alter the reward-anti-reward states of the addict’s neural network system, which in turn help to provide higher cessation rates and lower relapse rates. In addition to overcoming addiction, yoga and meditation also stimulate the three aspects of healthy aging namely: decreased morbidity, independence and mental equilibrium or equanimity (see Meditation: Effects on Gene Expression). What a cheap but effective method to empower ourselves. A perfect New Year’s resolution is to incorporate yoga and meditation into our lives! Don’t you agree? 

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Acute Orthopedic Injuries

by Shari

In my role as a physical therapist and yoga instructor, I see lots of clients and yoga students who have experienced both acute and chronic orthopedic injuries. In western medicine, an injury is considered acute rather than chronic when it is less than three months old from onset. In general, an acute injury is an injury that occurred as a result of a traumatic event, including:

• Muscle pulls
• Ligament sprains
• Fractures
• Dislocations
• Contusions (bruises)

Signs of an acute injury generally include one or more of the following:

• sudden, severe pain
• swelling, often with the inability to place weight on a limb
• extreme tenderness on palpation of limb or other body part
• inability to move a joint through full range of motion,
• extreme limb weakness, visible dislocation or breakage of a bone

In general, there are two types of acute injuries: an unexpected acute injury and a cumulative trauma. An unexpected acute injury is one that is sudden and immediate, for example, the result of a skiing accident or a fall. My friend Shelly Prosko, who will write a post for us in the near future, experienced an unexpected acute injury when she was Double Dutch skipping and ruptured her Achilles tendon. On the other hand, a cumulative trauma is one that has been building up for a long time, possibly due to micro-injuries to a specific, vulnerable area until a final “last straw” movement causes the injury. This was the case with my right knee medial meniscal tear, which happened during a yoga class when I was doing the same pose I had been practicing for many years.

After you experience either type of acute injury, you have a dilemma: do you seek immediate medical advice or practice the “wait and see” method? Obviously if you think you may broken a bone, have a concussion, are bleeding profusely or are in excruciating pain, you should go to the emergency room. Otherwise, if the injury seems minor, you can take a 48-hour wait and see approach. During this 48-hour assessment period, you can practice R.I.C.E first aid:

REST: The first 24-48 hours after the injury is considered a critical treatment period, and you should curtail your activities. Gradually use the injured extremity as much as you can tolerate, but try to avoid any activities that cause pain. Often using a splint, sling, or crutches is necessary to adequately rest the injured body part.

ICE:
 For the first 48 hours post injury, ice the sprain or strain 20 minutes at a time, every 3-4 hours. The ice pack can be a bag of frozen vegetables (such as peas or corn), allowing you to be able to re-use the bag. Another popular treatment method is to fill paper cups with water then freeze the cup. Use the frozen cube like an ice cream cone, peeling away paper as the ice melts. Do not ice a sprain or strain for more than 20 minutes at a time! You will not be helping heal the injury any faster, and you can cause damage to the tissues!

COMPRESS: Use compression when elevating a sprain or strain in early treatment. Using an Ace bandage, wrap the area overlapping the elastic wrap by one-half of the width of the wrap. The wrap should be snug, but should not cut off circulation to the extremity. So, if your fingers or toes become cold, blue, or tingle, re-wrap!

ELEVATE: Keep your sprain or strain elevated, higher than your heart if possible, to reduce swelling. Elevate at night by placing pillows under your arm or leg.

One of the most wonderful positions for reducing swelling (edema reduction) is Legs up the Wall pose (Viparita Karani). And you can even do this pose in bed if your bed is next to a wall and you have the agility to position yourself into the pose. If this isn’t possible, you can try using two bolsters propped up against a chair instead of a wall, especially if you have someone to place the bolsters for you. However, in acute trauma, this pose may NOT comfortable so short bouts might be more beneficial than longer periods of time.

Another spectacular pose for edema reduction is Chair Shoulderstand (see Judith Lasater's Favorite Poses), which you can do in a more passive position with your legs perpendicular or in more active position with your legs upright. The more passive pose is to rest your legs against the chair back, which requires less physical work and allows more relaxation (although this creates more of a backbend).

As you practice your R.I.C.E, keep assessing your pain levels. Sometimes the severity of an injury isn’t apparent immediately but if the pain worsens as the hours progress, this is a good indicator to seek medical care.

Ok, so your 48 hours have passed and you have religiously been practicing R.I.C.E. but you are no better, but no worse. At this point it is time to go to a medical doctor and learn as much as possible about the different possible treatments for your injury and then go through a careful decision process. And yoga can help you through all this.

In my situation with my right knee medial meniscal tear, I waited over six weeks of my own “conservative care” approach before the grim reality hit that things weren’t getting better. I didn’t follow my advice of getting medical help after 48 hours because I thought I could just heal my knee with a lot of RICE and restorative inverted poses. It did slowly get better over the six weeks but I reached a plateau in regaining movement and decreasing edema, and finally acknowledged I needed to be evaluated and diagnosed by a physician. (And frankly, I do have “white coat syndrome” and found it is easier hide my head in the sand and not acknowledge that my injury was more serious than I thought. There was no actual injury so I kept hoping it would get better. Sometimes we ALL practice avoidance!)

I then entered into the traditional medical model (see Fizzy Yoga!) and began non-surgical medical interventions. Along the way, I realized that I needed to add other C.A.M. (complementary alternative medical) approaches to my other endeavors. I realized that I needed to address all five koshas and sought out other medical practitioners that I trusted to aid me in my healing not just by addressing the physical injury but also by preparing me for the question that I had been avoiding: was I going to opt for surgical repair of my meniscal tear?

I meditated on the reason I wanted surgery and what would I gain from it. I had never in my 58 years had ANY surgical interventions, so even to contemplate surgery was a huge question for me to come to grips with. Many people told me to “just have the surgery, it is no big deal,” while others told me horror stories about failed meniscal surgeries and a NY Times article on why knee arthroscopy doesn’t work. But the surgeon who I consulted for this procedure was spectacular. He told me point blank that the decision was mine, but that I couldn’t be on the fence about it. I needed to believe it was the right choice for me. He even went as far to tell me that I could cancel in the surgical suite before anesthesia if I wanted to. His words changed the power dynamics and allowed me the space to meditate on my own fears and come to terms with them. He would do his job, but I had to do mine also.

Yoga helped me through the surgical process in many ways. Pre-op as I was waiting to be brought into the surgical suite, I was in a "comfy" type room with a recliner chair. I lay in that chair, covered myself with the blankets and practiced Ujaii breathing to calm myself. Also, I tried to clear my mind of all doubts and fears by just counting and following my breath. That practice helped immensely, and I was surprised on how low my blood pressure was when they took it before taking me into the operating suite. Just before the anesthesia was administered, I also tried to follow my breath as the lights literally went out. Post op in the recovery area again some Ujaii breathing helped to center me.

Once home, pranayama was helpful in quelling the anxiety and pain from the procedure. I didn't really start yoga asana practice till 24 hours post procedure. Starting with using my breath as I worked through my range of motion exercises and tried to be "kind” to my knee. Yoga is intimately connected to my current recovery. I really can't separate it out from my activities—everything I do now is with mindful attention to my knee and how it will respond to a new activity or asana position. Learning to GO SLOW is my current practice because when I don't, boy oh boy, does my knee balloon up! My knee is my teacher now and the rest of my body is the student—a different place to be for sure.

So, now it is two weeks post-op recovery. I have learned how to ask for help, which for me is really challenging. I have also learned that I need to still the little voice in the back of my mind that criticizes or is unhappy that I still can’t do something that I “should be able to do.” On the other hand, I’ve found it quite amazing how my knee has taught me how to experience asana differently. Yes, before I had to modify, modify, modify, but now the experience of gratitude is present. I ENJOY pranayama now and am practicing it more regularly. Also, I feel embraced by Chair Shoulderstand when I practice it. It is hard to describe but as soon as I am up in the pose I feel like I am getting a “big hug” that encompasses my entire being. The words don’t quite communicate the feeling of prana in my body!

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Baby, It's Cold Outside

For those who not have experienced Winter Storm Hercules , it's currently -10F at Unity Farm (not wind chill, that's -15F).    We have 10 inches of new fallen snow.

As I've written about previously, all the animals have protection from wind and water.  Wall mounted heaters are protecting them from frostbite.      At dawn we gave the alpaca and llama large bowls of alfalfa mixed with molasses.   The chickens and guinea fowl ate hot oatmeal mixed with dried cherries.   The ducks got a warm duck soup of chopped greens and warm water.    The dogs got an extra helping of their favorite dog food.   The rabbit got a very sweet banana.

Here are a few photos at -10F from Unity.    Yes, an iPhone 5S works well at that temperature, although fingers using the phone do not last long.

I added bricks to the top of the bee hives to prevent the covers from blowing off.   We added sugar feeders to the inside of each hive and replaced the hive opening with a very small "winter" front door.  A capping of snow insulation is keeping them warm.  

We refilled every bird feeder, ensuring our juncos, chickadees, bluebirds, wrens, finches, titmice, woodpeckers, cardinals, and nuthatches have maximal nutrition.

The cider house is keeping all the apple picking and beekeeping equipment safe from the elements.

We shoveled all the paths and gates for easy access to the coops and paddocks.

The hoop house is a balmy 28F, keeping our winter vegetables growing by trapping the heat of the sun.

The blowing snow drifts created Zastrugi in the orchard 

The pastures are covered with a blanket of snow.   After 2 years of moving snow, mulch, and manure with a hand drawn wagon, I'm finally considering a tractor.

Shiro, our 120 pound Great Pyrenees male, has very big paws for scrambling through snow.

The duck pond is frozen and covered with snow, although the water is still circulating below the surface.     The ducks bathe in their 50 gallon stock pond that is heated to 40F.

We dug out the garden shed to access all our snow management tools.

Shiro kept a close eye on everything during the storm.

We removed the roof from the mushroom house to keep it from collapsing under the weight of ice and snow.

We have three mushroom "laying" yards where fruiting logs are kept for harvest.   At this time of year, the only creatures exploring the laying yards are deer, rabbits and foxes.

The dogs are begging for a run on the trails, but at the moment only deer are running through the 10 inches of loose powder.

I've split 8 cords of wood for heating this winter.   We'll use half a cord during the duration of Hercules and the freezing days to follow.

Stay warm!

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Building Unity Farm - Making Mead and Cyser

The entire family visited Unity Farm for the holidays.  After all the gift giving, merry making, and
yuletide time by the fire was over, what should a family do at a farm with apples, honey, fermentation equipment (there's a basic chemistry lab in the cider house), spring water, and microbiology know-how?   Make mead of course!

Mead was the earliest fermented beverage created by man - evidence of honey and fermentation products begins about 9000 BC.   Mead figures prominently in Hindu writings, the work of Aristotle, and the Old English poem Beowulf.  

There's a new vocabulary to learn when deciding how to make Mead.

"Show" Mead - a higher alcohol, full flavored mead made with more honey and less water
"Small" Mead - a lower alcohol, lightly flavored mead made with more water and less honey (Queen Elizabeth the First enjoyed a very dilute mead)
Melomel - mead with added fruit or fruit juice
Pyment - a melomel made with grapes and often herbs.   You could call it a honey-fortified wine
Cyser - a melomel made with apples.   You could call it a honey-fortified hard cider
Zythos or Braggot - a mead fortified with malt.   You could call it a honey-fortified beer
Morath - a melomel made with mulberries
Metheglin - a mead made with herbs or spices.   The name means "Mead of the Glen".   Some believe it is the root of the term "medicine"
Rhodomel - a metheglin made with roses

At Unity Farm, we tend to prefer our beverages fermented dry.  We often create both sparkling and still versions of our beverages, but I only make still mead after a bad experience with exploding bottles as a mead maker in my 20's.   Here's the approach we used during the holidays:

Unity Farm Mead
 3 quarts water from our 600 foot deep well
 3.5 cups Unity Farm Orchard Honey (wildflowers and clover)
 1 teaspoon acid blend (citric/malic/tartaric acids)
 5 grams Redstar Pasteur Champagne yeast
 6.25 grams Go-Ferm yeast nutrient in 125cc's of 110F water
 10 grams of Fermaid-K

Heat the water to 160F, add the honey and acid blend.   Simmer for 10 minutes and do not boil.   Skim any foam from the top.   Pour into a 2 gallon sterilized fermenter (we use food grade buckets with a drilled lid and airlock, pictured above).    Take a ph or specific gravity measure if you wish.   Our 12/29/13 batch had a specific gravity of 1.090 and a ph of 3.43, giving us a potential alcohol level of 12%

Add 6.25 grams of yeast nutrient to 125cc's of 110F water.    At 104F add the yeast and wait 15 minutes.   Cool 100cc's of the honey/water solution to 104F and add it to the yeast solution.   Wait 15 minutes.   The resulting yeast solution will be frothy with new yeast growth.

When the honey/water solution in the fermenter is 104F add the yeast solution.    Place in a room with a constant temperature in the low 60's for slower, more flavorful fermentation.

After 1 day, add 5 grams of Fermaid-K

After 1 week, add 5 grams of Fermaid-K

After 2 weeks, rack the solution with a racking cane into a sterilized gallon jug and seal it with an airlock.  Leave very little air space  in the jug (1/4").  Top up with water if necessary.  After 2 months, sterilize the mead with 50 parts per million of potassium metabisulfite, then bottle and age for 6 months before drinking.

Unity Farm Cyser
 1 quart water
 2 cups Unity Farm Meadow Honey (wild asters and japanese knotweed)
 1 teaspoon acid blend (citric/malic/tartaric)
 1 cup black tea (steeped 3 minutes at 200F)
 2 quarts Unity Farm unfiltered Apple Cider (made from 11 types of apples)
 1/2 teaspoon pectic enzyme
 5 grams Redstar Pasteur Champagne yeast
 6.25 grams Go-Ferm yeast nutrient in 125cc's of 110F water

Heat the water to 160F, add the honey, acid blend and tea.   Simmer for 10 minutes and do not boil.   Skim any foam from the top.   Pour into a 2 gallon sterilized fermenter.    When the mixture has cooled to 110F, add the cider and pectic enzyme.

Take a ph or specific gravity measure if you wish.   Our 12/29/13 batch had a specific gravity of 1.085 and a ph of 3.56, giving us a potential alcohol level of 11.3%

Add 6.25 grams of yeast nutrient to 125cc's of 110F water.    At 104F add the yeast and wait 15 minutes.   Add 100cc's of the honey/cider/water solution to the yeast solution.   Wait 15 minutes.   The resulting yeast solution will be frothy with new yeast growth.

Add the yeast solution to the fermenter.    Place in a room with a constant temperature in the low 60's for slower, more flavorful fermentation.

After 1 day, add 5 grams of Fermaid-K

After 1 week, add 5 grams of Fermaid-K

After 2 weeks, rack the solution with a racking cane into a sterilized gallon jug and seal it with an airlock.  Leave very little air space  in the jug (1/4").  Top up with water if necessary.  After 2 months, sterilize the mead with 50 parts per million of potassium metabisulfite, then bottle and age for 6 months before drinking.

Although we've not enjoyed the flavor of commercial melomels, we will create our own blueberry, raspberry, and elderberry melomels this summer when the berries are ready.

Mead is an acquired taste and you will want to experiment with different styles to find the right mead for you.   Hence I recommend 1 gallon batches that enable you to evaluate each recipe variation but not create an overabundance of something you'd prefer not to drink.

Happy mead making!

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The Year That Was 2013

As the year drew to a close, I was interviewed by many trade publications about the key themes that shaped 2013.   Here's my own version of the notable events of 2013.

1.  Meaningful Use changed the EHR landscape
Regardless of your political affiliation, there is little debate that EHR adoption in the US achieved a tipping point in 2013.   Here are our Massachusetts statistics from the 2013 Massachusetts Medical Society survey

The current overall percentage of EHR use is 79% (N=201, CI=5.6) and 82% of those using EHRs have had access to this technology for more than 2 years. Extrapolated to the estimated 18,000 clinical physicians in the state, that would leave less than 3,500 clinical providers without access to EHR systems (3% of respondents indicating that they are no longer in practice).

Broken down by practice size adoption rates are:
1-9 Physician practices made up 66% of respondents and had an adoption rate of 75%
10-25 Physicians practices made up 13% of respondents and had an adoption rate of 96%
26-75 Physicians practices made up 6% of respondents and had an adoption rate of 100%
>75 Physicians practices made up 12% of respondents and had an adoption rate of 97%

2.  Healthcare Information Exchange developed great momentum
Meaningful Use Stage 2 and more importantly the Affordable Care Act motivated organizations to implement push (via Direct and HISPs), pull (via regional and state HIE activities) and view (among clinical affiliates) interoperability for care coordination and population health.   As a CIO, I'm no longer the lone voice driving interoperability top down, it has become a bottom up demand.

3.  Security and privacy became Board-level issues
Meaningful Use, compliance requirements, and enterprise risk assessments elevated security and privacy issues to top priority for many organizations.  CIOs are hiring new security staff, enhancing capabilities, and expanding budgets to address increases in threat sophistication and volume.

4.  Self built EHRs became increasingly rare
Partners Healthcare and MD Anderson adopted Epic.   Intermountain Healthcare adopted Cerner.  That leaves Beth Israel Deaconess and the Marshfield Clinic among the few healthcare organizations building applications to enhance innovation and reduce cost.    An unintended side effect of Meaningful Use Stage 2 certification criteria was that provider self built systems, niche specialty applications, and small EHR vendors all became rare.

5.  Innovation slowed as the regulatory combination of ACA, ICD-10, MU2, and HIPAA Omnibus rule dominated the agenda for IT organizations.

The work I've done on Natural Language processing, Google Glass, advanced analytics, workflow enhancement, and patient/family engagement was limited to nights/weekends and the strength of will of selfless volunteers who innovated outside the workday.

As Meg Aranow guest posted on my blog in 2011, the content of being a CIO in 2013 continued to be great, but the context became even more anxiety-provoking .   Demand exceeded supply, anxiety/tension escalated, and budgets became even more constrained (except for selected security/compliance projects, which are often seen as burdensome rather than beneficial by customers).  The holidays brought a welcome reduction in post traumatic stress disorder symptoms for many CIOs I know.    However, on the positive side, I've always felt that times of great struggle are opportunities for greatness.   We are living in the most transformative time for healthcare in the US, and the worsening CIO stress is just a side effect of accelerating change for all healthcare stakeholders.   I recently wrote about the mitigations we need to consider to get through each day.

Personally, 2013 was a combination of emotional highs and lows.   My father died in March.   My mother entered a new chapter in her life requiring resilience and new skills.  My wife's cancer is in remission although she still experiences the side effects of chemotherapy, peripheral neuropathies and muscle spasms, that impact her activities of daily living.   My daughter thrived at Tufts University in 2013, maintaining her own apartment, living independently, and viewing the world with increasing sophistication.

Unity Farm continued to grow in 2013 with 11 chickens, 10 ducks, 29 guinea fowl, 11 alpaca, 1 llama, 2 Great Pyrenees Mountain dogs, 3 cats, and 1 rabbit in perfect health.  2013 was the year our orchard was born, the cider house was built, our duck house/pond was created, and we established a regular routine for efficiently managing all 15 acres of woodland, pasture, and wetland.   We obtained various licenses and certifications to begin selling our jams/honey/cider/mushrooms/vegetables and learned a great deal about producing organic, handcrafted products.

The combined responsibilities of leading IT for a growing ACO, assisting several countries with IT strategic planning, working on US national standards, championing state healthcare information exchange adoption, and being a Harvard Professor strained my endurance at times, especially early in the year when I made 5 visits to California around the time of my father's death.   Trips to China, Japan, Taiwan, and London were all important, but required boundless energy to ensure my day jobs were fully supported while I was half a world away.   2014 will have much less travel than 2013.

I turn 52 in a few months and as I reflect on the year that was 2013, I can say it was one of the most difficult on the journey thus far.  However, at the end of the year I feel the trajectory heading into 2014 is right.   The healthcare environment will still undergo tectonic shifts but my family, friends, and colleagues will make it navigable.    I will reaffirm my quest for equanimity in all difficult situations, my veganism, and my balance of work/farm life.    May 2014 be happy and healthy for all of you and enable you to make a difference.

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